Nowadays, oncological breast surgery has to be performed to maximize cosmetic results, and even mastectomies, when unavoidable, should conform to acceptable aesthetics. We investigated surgical approaches to skin-sparing mastectomies. Scar positioning and volume replacement were evaluated. We also discuss nipple-sparing mastectomy (NSM), probably the most outstanding item in the current debate on breast shape preservation. We give suggestions for safe admission criteria and effective treatment.